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4. The Work of Policy Change: Christina Hurlock-Chorostecki

This episode focuses on NP regulation, legislation and policy. Although the experiences that you'll hear are about the province of Ontario and Canada. I think you're going to find that the experiences the situations and difficulties are mirrored across Canada, and actually across the world. If nothing else, I think you'll be reminded of all the efforts that nurse practitioners made in the early days of our profession in any location to ensure that nurse practitioners could work to our full scope of practice.

So today, I'm really excited about our guest. Her name is Dr. Christina Hurlock-Chorosteki

and she was a Past President of the Nurse Practitioners' Association of Ontario, among a great many other things. I'm really pleased that Tina's here today to talk to us and welcome Tina and, would you please just start by telling us a bit more about yourself?

Hi, thanks for the opportunity. This is a great honour to be able to talk on a podcast and I think it's a wonderful thing that you're doing to help news practitioners be connected and connected to the leaders, past and future of news practitioner work.

And like you said I was a President of the Nurse Practitioners' Association (of Ontario). I joined that association the minute I took a role in London (Ontario) as a nurse practitioner. Now that was in a hospital. So it looked different from what nurse practitioners were doing at the time. Most of them were primary health care, and I didn't have this practitioner education at the time, a lot of my education came actually from clinical. But there was a course in University of Toronto for what they call the acute care nurse practitioner so I did take that and worked as a nurse practitioner in intensive care for a number of years.

As a member of NPAO, I was really passionate about the role I thought it was such a great role, so helpful to the patients and families that we were looking after. I met a large number of, nurse practitioners that worked in the hospital, and I knew just have to have the primary health care NPs.

But, becoming a member of NPAO, I was only a member for a couple of years before as I'm going to join the board, I was so passionate about that.

And I think, Roberta, that's when you and I met you were on the Board at the same time as I was. Yeah. And it was exciting times.

We were always trying to change things everything. We were always working to move things forward. And I thought that was a really cool thing to do.

I stayed on the Board as one of the regional reps, and then I moved into the secretary role.

And then I got invited to be in the President role. It sounds kind of odd, but there weren't a lot of people wanted to be on the NPAO board because it was such a busy life being a nurse practitioner, and there just wasn't time.


And so, the board members kind of got together and talked about, who are the people that they thought would be good leaders. I was asked if was going to be President and I said, "I don't think so, I don't have those qualifications." But then in talking with them, and they encouraged me and they said, you know, we would provide you support, like the previous President would provide support and things like that, and said okay I'll give it a try.

Well, I was really pleased with the type of education that I got as a Board member, one of the things that I think was so important for me as a Board member was when we learned about the difference between legislation and regulation, which is all political talk, right?

So what is this all about? Well, a lot of the stuff we do as nurses and nurse practitioners is all in Bills and laws and regulations, all that type of stuff. So that was one of the big things that I learned as a Board member, and it really helped me because the whole thing blew up in the year I was in the presidency. We had so many opportunities to move the nurse practitioner role forward, both primary health care, and the what we were called, acute care, at the time.

Yeah, it's true. And you know, when I think about it. I'm just to get a bit of context.

When our legislation/ regulation allowed us to prescribe, for example, from a very restricted list and to order diagnostic tests from a very restricted list. And, you know, it's funny because our regulation and legislation that if you will. And, you know, it's funny because our regulation and legislation, if you will. Other jurisdictions across Canada and across the United States, and actually across the world are finding that they're in the similar problem, that there are so many restrictions and that nurse practice organizations have to chip away at the little by little. I think it's what's interesting about your tenure as the president of NPAO, is it seemed to be a focal point for when a large number of changes happened, so I'm just wondering, you were just about to start to talk about some of them. Happy to listen to your experiences about them.

The experience was unbelievable. Of course, I was still working right and I was working every day in the hospital. As a nurse practitioner, you know it all worked long and hard.

And then I would come home and I do all my political work. It came to the point that my husband would slide a plate of dinner in front of me between me and the computer at a time.

Sometimes he would come to the door at midnight and say, you have to go to bed. You have to go to work in the morning, so there was a lot of work.

I used to talk to NPAO was related to RNAO, we were a interest group at the time, and Doris Grinspun would call me at 10 o'clock at night because she had heard something from the Minister of Health office, and we would have a conversation about that and how we going to deal with it and things like that. So it was it was it was really something.

It speaks to the kinds of sacrifices that many people made because just to put things in perspective, this is a volunteer role. There's no remuneration for it. So, the people who sat on the Board of the Nurse Practitioners' Association of Ontario, for the most part, were completely voluntary. It was completely voluntary and there was a lot of work. Actual slogging it out in the trenches, kind of work at the beginning.

It was, was and when I took the presidency I talked with my Chief Nursing Officer at the hospital, and the physician partner that I had and said that this, this is an important thing. We have a feeling that there are some big things that are going to happen in this time period and they were very supportive. So I'm, I'm very appreciative of that.

But some of the things that happened. The HPRAC I don't know if people know what HPRAC is, it's what's it called the Health Professions Regulatory Advisory Council, and it's a group of people who, the Minister of Health says, "Hey I've got a question. Go out and find the answer" So, HPRAC was very busy in that time period. First thing they did was they did a scope of practice review of the RN extended class. And what HPRAC does is they go out, they talk to all kinds of groups, organizations, individuals and all types of things, to find out what is good, what was bad what we can change etc. And that was really important that was an important piece to get started the whole ball started rolling after that. So, what was the main thing that came out of that was the whole list prescribing thing. Now I remember that painful list I hated those meetings when we sat down and said, "Okay, we have to pick three drugs for this year, no more than three, and then we have to sit down and write a, you know, 30 page document on each drug that says this is an important drug for nurse practitioners to prescribe", and then send that in and wait and see if somebody reviews it and let us prescribe it. That it was ridiculous. It was terrible.

But, in the hospital. All those nurses in the hospital, nurse practitioners I mean, in the hospital, worked under a medical directive at the time, and what they had was a list, my list in my medical directive, was the entire formulary. I wrote prescriptions for everything in the hospital, not for the patient to take home, but in the hospital. So, big, big difference between those two groups of people. We're all the same. So, why can't we make it all the same? So that was kind of the focus of that year, and something that came out in that aren't extended class review.

Why are these so different?

We used a lot of that information when we came down to the next one, Critical Links, I think was the name of the next one. Critical Links brought up some things where people in government, "Did you respond to a therapist can't even order oxygen?" and I said, "Did you know that nurse practitioners can't either? Or blood, or blood products?" Those are all important things in the hospital so we got that identified and move forward on that.

But then became the one that was called Interprofessional Collaboration and Non-Physician Prescribing was another one. And each of these documents. Our board and our admin assistant that we had at the time, we sat down and we wrote large documents. We got information from all the nurse practitioners that were practicing to show examples of why the list, was not providing good care for patients. So, we had to move forward on that.

Oh, I can't remember where it came...we need to actually make sure that nurse practitioners are nurse practitioners, so we went for title protection.

I remember that.

Yeah. And the problem with that created was all those people working in the hospital like me, who didn't take the primary health care education, could no longer be called a nurse practitioner, even though we had a certificate. You know, a master's level education, all that. So that really caused a big split in the nurse practitioners, but we moved forward. The College of Nurses made the different specialties so the primary health care, the adult pediatrics and then they added anesthesia as well. That's another whole topic, because that's sort of disappeared off the list.

But can I just interject? So, just for clarity then, the title protection meant that nobody, unless you were regulated and legislated as a nurse practitioner, could not use the word nurse practitioner, you can't use the title. So, what had happened just to clarify, was that at the time, the only type of nurse practitioner that was recognized in the legislation/regulation was a primary health care nurse practitioner. Just to put that in perspective. Regardless of the fact that there were education programs and certification programs for a variety of others. Neonatal, I think had been a nurse practitioners for decades, and of course acute care nurse practitioners, the term we used for care in the hospital setting. So, it really did create...It was a sort of like a bureaucratic nightmare that created more problems solved at the time. I mean they eventually got sorted out but it just demonstrates how difficult it was because each and every tiny little thing that we had to address had to go through numerous levels of approval at, you know, through the Ministry of Health through the government through the College of Nurses in order for us to have reasonable practice, seamless practice, and an acknowledgement of the different levels of expertise. So, I mean, I can't I just think back to the days that you were president I just shake my head.

Yes, there were times that I actually would be traveling to a family event, and I'm on my lap I've got my computer and papers, and I'm riding in the car. And, you know, I had to stop because we were going to cross the border and not going to have, you know, what I needed and I had to close things off and I had to call in. I just had to forward it to the next person to review it and do all those things.

Some of the other things we actually did at that time. Well that was actually once the Interprofessional Collaboration document came forward and out for review to different organizations, was we lobbied for removing the list prescribing for nurse practitioners and saying that it was just ridiculous and we needed the nurse practitioners because there aren't enough physicians to care for all the people, and that includes in the hospital. We needed the acute care nurse practitioners to be part of the same body, because with bringing them in with the primary healthcare, these people have been prescribing pretty much an open and prescription type thing, safely for all those years, like you say Roberta.

So, we have to bring that in to be that support for the primary healthcare, who have been limited under this list all this time to say "They don't need to be." "See, we've shown you." So we had to bring that together, we had to bring those two groups together. And like you say, big challenge with the protection of the title of nurse practitioner caused a rift between those two groups but we work to pull them back together, but it was interesting, to move forward the open prescribing and Bill 179.

That's right. But you know what, if I'm not mistaken, in the review of the Non-Physician Prescribers did the committee not recommend an additional layer of approval for the addition of new drugs on to that list? So rather than look at all the evidence around the world, and within Ontario, about safe prescribing, open prescribing, they chose to add an additional layer of approval. So, if I'm not mistaken, you had to go in front of a government committee and present. That was sort of our last-ditch effort, otherwise we would still be having a list and we still have that we'd have that additional layer. Crazy.

That's true. Absolutely true and it was, it was a government committee, there was a health critic from each of the parties (government political parties), sat there. There was a guy up in the corner sitting up nice and high, and he was the guy that you sat in front of these people with a microphone and you had 10 minutes, and when 10 minutes came across, he pressed a button turn your microphone off. You had 10 minutes. Terrified! I didn't know who to talk to, I talked to a friend of mine, Mary Van Soren, she was an educator in primary Health Care for many years. And she said, "I'm going to put you in touch with someone who used to be the Nursing Secretariat" she was actually the first nursing Secretariat (Kathleen MacMillan).

Anyway, so I talked to Kathleen and she said the most important thing for you to do is to do an eight -minute talk and leave, two minutes for each of those people to, to ask questions.

If you let them ask questions that's going to be more powerful than you just talking. So that's what I, that's what I did and actually all three of them did ask me a question, and I got to, you know, give them some support.

Um, what was some of the things I'm just looking at some of the things from my talk that I had. I remember saying that the Bill 179 was a good move in the right direction, but, it represents a timid and insufficient response to real problems for Ontarians and system. And then I went on and talked about the extensive research of nurse practitioners and how there has been no studies that have demonstrated any harm to patients from all of this. The thing is that I had to get the numbers because when you talk to people in government, they want numbers they want research stats. There are 13 randomized control trials, and none of them demonstrated any harm, you know. But then they like stories too. I didn't tell them any stories like that, but I did tell them you know, other jurisdictions in Canada have more open prescribing and we do in Ontario. We were the first ones to have NPs, but now we're lagging behind and, and it went on and on about the research, and this I didn't go on and on

Within your 10 minutes!

Yeah, I said, you know, we really have to step up and bring Ontario back to the same level or even the forefront. You know, we used to be the front runners but not anymore.

So, my final message to them was no Ontario NP Left Behind. No Ontarian, waiting for a national standard of care.

Wow, that's amazing.

We really had to do that stuff. The other thing I had to do was media so media thought this would be really cool. Doctors hate nurse practitioners because they're taking their job away, which was quite often, a feeling I think some of that was going away with all the work that the primary health care NPs had done. But, so I get these calls from media, Can you be on this? Can you do this? So I had a request to do a CBC interview early in the morning. And I said, well, gee, I was getting on the train at that time so I have to take the train up doors were meeting with

a group of practitioners, I'd be happy to do it but I'll be on the train. And I said, Okay, yeah, we'll do it anyway you know your cell phone sounds pretty good so we'll do it. So picture me with a small suitcase with a couple changes of clothes and my cell phone, running down the track to get on the train, while I'm giving an interview on CBC live. It was an unbelievable thing to do.

Exactly. I wrote down media savvy because I don't think people understand how important having a strong understanding of how the media works and how you need to address issues with the media and how I mean, certainly, with the Nurse Practitioner- Led clinic in Sudbury, for example, we had a policy that it was positive messaging. Positive messaging. Because

we weren't going to enter into any kind of wars with anyone. There was no nothing to gain from that and there was no truth and a lot of it. So it was really important to just highlight how important nurse practitioners were and the good work that we were doing. But it took some time to get to the point where you knew how to do that without, you know, putting your foot in your mouth and causing trouble.

One of the things I did as President I sat down with the Board and I said okay we need to come up with, because all these things were happening, we need to come up with three things.

So, there are three things that are focused and we will always focus on that. I actually can't tell you what the three things were. I don't remember, but I said to them, if anybody asks you a question, it doesn't matter what the question is, you answer with one or two of those things. You just change it around, and I had to do that in those media interviews because they wanted me to say, "Doctors are stupid and doctors are mean" and all these types of things and then they would get a doctor on who would say nurse practitioners are useless. And it'd be this big fight. And like you said you can't do that, you have to do the positive. So, that's what I would do. And my husband listened to the interview that I did, and then call the afterward and he was laughing He said "You controlled that whole interview. She kept asking questions and you had a whole different agenda as obvious as it was really good."

Good for you, you know it's true because journalists, often will pick up the small pieces that they think will be of interest to the public, but also would get them the, what we call it clicks now the time it really wasn't social media wasn't as prevalent, So, but, absolutely. So, it's a skill.

Yeah. Well, it was so exciting the Minister of Health at the time was Deb Matthews, and she was also my MPP. So, I use that and had a couple of appointments with her to, you know, very briefly talk with her. And I had said to her, when we were doing the Bill 179 and things had moved forward and we got rid of the list in the Bill. And then it was in for Reading so when you, when you have a Bill, it has to be read three times in to the, to the, sitting government, and then it has to be passed each one of those times and usually there's amendments. And when it was at a third reading and then it goes to be a law, I wanted to be in the crowd that was at the top. And so I said to her when that's going to happen, call me. I will come to Toronto and I will, I will do that because I was in London. And she called me the day after it went into law and she said, "I couldn't call you" because we were going to stop everything they had gone on late into the night. doing the Bills to get them through, and the speaker said "Well, do you want to do this bill now or not?" and she said, "Well, I couldn't call you, because I didn't do it then, it might not have been put through if we put it off for another time" So she just went through with it. I was so thrilled that that happened.

I remember getting that email that Bill 179 went through and that the drug and lab list was gone. It was like six in the morning, I got up check my emails and the executive director of NPAO had sent it out. I started screaming, I woke up my husband. It was just nuts, but it sort of was a combination of so much work and effort Unfortunately, that was, I think it was enacted October 1, 2011 if I'm not mistaken, the drug and lab was removed, and as of July 1 we're still chipping away at some of the some of the restrictions that were apparently removed by 179 so you know that's a long time it's not 2022 so you know these things didn't happen overnight.

To get the legislation passed. And now to get to remove the restrictions based on that legislation has taken well over a decade, doesn't end, it seems.

It's all the other regulations hidden in other Acts that that are such a problem, like the lab list. Well some of those things were in the Lab Act so we had to wait for the Lab Act to be open before we can lobby for the changes in there, and that. Yes, what a nightmare and somebody needs to have a huge spreadsheet in front of them to say, these are all the things we need and these are all the Acts they're in.

If I'm, not mistaken, and I'll check to see if this is true, but I think other provinces used an Omnibus bill that where the, the bill for the nurse practitioner legislation, just sort of allowed them to have all those little pieces addressed through their one piece of legislation. So with us, it was like, "Oh yeah, the Ministry of Health says you can do this, but now you have to go to this department and you have to go to that department and you have to change that law, and that law that law. It's been unbelievably cumbersome, and I don't know why.

Some of the laws there for so long ago. It was, it was really something. But, we broke the ice. We got the big chunk moving that, and it's been, like you said, each President after me has had to work very hard on finding little pieces and getting those things moved forward and getting those off of, you know, getting those away from being and lists as well.

Yeah. So, I don't know what of all of the things that you did as the President, and even in your time in the Nurse Practitioners' Association of Ontario, what would you say was the most meaningful maybe to you, or had the most impact? Is there anything that stands out?

The most impact...hmmm....I'm trying to think, removing that list was probably the thing that was closest to my heart. I thought I brought the two groups of nurse practitioners back together. Because now we were the same. It wasn't one with this limitation and the other one didn't have it. And I really worked, and wanted to work very hard to bring that group back together and it's all be the one thing and we're all called nurse practitioners. Nobody's better than the other one nobody does more than the other one. And I see it in, when you look now at where people are working. You can find Primary Health Care Nurse Practitioners working in cancer clinics and hospitals, not just not just things... at one time they put the primary healthcare NP could work in emerge. So, that was great. But now, now those people can do.

One of the other things who worked on was regulation 965 of the public hospital side. So, nurse practitioners of any type can admit treat and discharge patients from hospitals.

So, those are other things that brought us together as one group, and you can see them crossing lines. The adult nurse practitioner can work in a doctor's office working or, or an NP-led clinic, or any clinic for that matter, and look after adult patients. Right? So it was all just getting rid of those stringent lines and bringing us back into one group. I think that was the biggest impact for me.

Certainly, it was, it was phenomenal for people like me who was a primary health care nurse practitioner in community settings. Because working with that drug and lab list was really like working with one hand tied behind your back, it was so, so, so difficult and. So all I can say is that you know I saw the work that you're doing, I didn't, I didn't even know all of it, but I do understand that it was massively intensive. It was a huge amount of effort and you know what it was people like you who really made a difference. So, thank you very much. I think it would have been easy, because of our lack of resources, for nurse practitioners to just have allowed things to stay the same. And it was a very small and very determined group moved and moved and moved to get things done and it really has made a huge difference in our healthcare system so I think you should take a lot of credit for that.

I thank you and I may have to also give the credit to the Presidents before me and the President's after me because some of them laid some of the foundation. The others are moving all the other pieces forward. But I think I happened to be the one that was there at the time when it all came together and it was, we go for it all, or we don't go for any of it. And we got that started and things were great, after that, yeah.

Do not back down. No nurse practitioner left behind is that what you said. No NP left behind. Yeah, boy, you know it feels very much like, you know, war rhetoric almost to do that.

Yeah. Have to make your point, you have to make your point to people who are listening to, you know, the government people who are listening, and like I said they like, they like stories the stories aren't going to get you the facts, you got to give them numbers. And really, if you want to do anything like this, you really have to learn how to speak to them and like you say to media as well. So, you need to learn how to speak the media, how to speak to government officials that that are going to help you do things so like even things like the Queens Park day. It's a great opportunity to go forward and actually speak to some of these people, but we should be going out and speaking to our own MPPs and saying, "Hey, look at this! This is what we should be moving forward in health care and how can I help you to do that?" and things of that nature, given them the facts.

That's right and it's becoming, it's not less important it's still extremely important but it's becoming a little bit less difficult to provide that kind of information because nurse practitioners in Ontario for example now I'm working in every aspect of healthcare, in every jurisdiction, and are really making their mark so it's becoming a lot easier to demonstrate our value in that respect. But is there, just as we're closing, then, just wondering if there's anything else that you wanted to add about this discussion?

Um, no, I don't think I might add anything but I think I would suggest to all expect us to try make an effort to do something, look forward on something, whether it's going to see your MPP, whether it's taking a course on house legislation work, how does regulation work any of those things. Be aware of what's going on. We just had an election in Ontario yesterday, right, and, well, "Did you vote, did you vote? Did you look at what these people are offering, where they get good things, how are you going to work towards improving those types of things who would be influential?" "Do you know who the, it used to be a nursing secretariat in Ontario but they removed that, but we have a Chief Nursing Officer, you know where that is? Have you have you emailed her? She'll email you back. I know her really well it's, Michelle Acorn, or and you know her as well, Roberta.

I don't think she's the Chief Nursing Officer anymore. She took a job in policy with the International Council of Nurses. Yes. Yeah, but I know exactly what you mean.

In fact, I think she would email you back regardless, and give advice and some support because I think that's the other thing that the nurse practitioners that I came through, came up through the years with are also incredibly supportive and helpful of each other. Sort of like you agreeing to do this podcast today.

The opportunity was great. Oh, Thank you very much.

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